Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 04
This report estimates subtotals of units and fees for the number of days of overlap between each included
FSPSA record and the user-selected report period. For example, if the FSPSA record authorizes services from
01/01/01 to 08/01/01, and the Report Period is selected as 01/01/01 to 03/01/01, this summary calculates
authorized units/fees for the 28 days of overlap (02/01/01 to 03/01/01). Note that service authorization periods
may range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs overlapping: 04/01/09 and 06/30/09 Date of Report: 08-25-09 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
Services Cpt Code Number of Number of Total Units Total Fees Avg Fee
Children Records Overlapping Overlapping Per Unit Auth
Report Period Report Period
Service Coordination, Class # 01
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 1.00 $37.00 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 1.00 $37.00 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 30 31 43.00 $2085.50 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 2.02 $121.33 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 4.00 $478.40 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 95 103 166.43 $8321.43 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 3 3 3.00 $150.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 250 313 344.92 $16728.80 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 209 247 291.00 $14113.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 305 358 420.00 $20370.00 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 2.37 $118.34 $50.00
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Subtotal (Total Children Is Unduplicated) 645 1061 1278.74 $62580.90 $48.94
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 14 16 46.40 $2320.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 154 204 416.63 $20831.35 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 0.07 $1.67 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 60 74 144.54 $7227.19 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 43 48 110.87 $5543.30 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 103 140 256.05 $12802.65 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.83 $45.83 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 77 113 720.00 $18000.01 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 749 1026 7827.47 $391373.69 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 352 467 2775.30 $188387.49 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.57 $85.36 $54.32
PHY -97110 PT SESSION BY LICENSED PT 345 449 2604.78 $176812.38 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 0.43 $23.28 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 46 58 45.08 $45.08 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5264 EARMOLD 3 3 7.76 $145.18 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 18 23 72.48 $3624.05 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 412 515 2676.22 $181661.92 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 9.64 $127.29 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 667 946 5710.36 $2855.18 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 15 19 74.93 $3746.31 $50.00
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Subtotal (Total Children Is Unduplicated) 1049 4110 23507.41 $1017724.19 $43.29
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Total 5172 24787.15 $1080342.09 $43.58
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Number of Children (Unduplicated) With at Least One Authorization 1089